1. Determine Level of 99 Code 1

2. EM Rules in CPT Manual 9 pages, starting pg 4, CPT 2013 EM Rules by Medicare 15 pages of 1995 Documentation Guidelines (DG) for EM Services 53 pages of 1997 DG for EM Services (skip pg.14-24, 27-45) 2

3. Determine Level of 99 Code November 2005- Medicare carriers are to use 1995 and 1997 DGs to review EM Services (whichever is more advantageous to the physician) until further notice (whichever is more advantageous to the physician) until further notice 3

4. Determine Level of 99 Code Non-Medicare plans may or may not use DGs Advantages to use them anyway – a) Defendable during audit b) Improves on ambiguity of CPT 4

5. Determine Level of 99 Code Website for DG 95 & 97 http://www.cms.hhs.gov/MLNEdwebGui de/25_EMDOC.asp http://www.cms.hhs.gov/MLNEdwebGui de/25_EMDOC.asp 5

6. Determine Level of 99 From Chart Documentation Only way to guard against audit losses 6

7. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History 2. Examination 3. Medical Decision Making (MDM) 7

8. Determine Level of 99 From Chart Documentation Grade each Main Element Use chart to choose final 99 Code Slow start - Quicker as weeks pass 8

9. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History 2. Examination 3. Medical Decision Making (MDM) 9

10. Determine Level of 99 From Chart Documentation History Inadequate history is single most common reason for downgrading during audit Record history the same way, the same detail, for all patients 10

11. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History 11

12. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History 12

13. Determine Level of 99 From Chart Documentation Chief Complaint (CC) Concise statement describing symptom, problem, condition, diagnosis, physician recommended return, or other factor or reason for encounter Usually stated in patient's words 13

14. Determine Level of 99 From Chart Documentation Chief Complaint Staff may take CC If staff takes CC, physician must validate CC in documentation 14

15. Determine Level of 99 From Chart Documentation Chief Complaint Required for every level of 99 code No CC means visit is not medically necessary, and not medically billable 15

16. Determine Level of 99 From Chart Documentation Chief Complaint Record as many CC as patient mentions Record as many as you are following at that visit Numbering 1, 2, 3, etc. 16

17. Determine Level of 99 From Chart Documentation Chief Complaint Related to complexity of Medical Decision Making MDM is "number of possible diagnoses" More complaints create more diagnoses 17

18. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History. 18

19. Determine Level of 99 From Chart Documentation History of Present Illness (HPI) Chronological description of development of patient's present illness from first sign and/or symptom, or from previous encounter to present Only physician can take HPI. 19

20. Determine Level of 99 From Chart Documentation HPI Elements (record 4 of 9) LocationQualitySeverityDurationTiming 20

21. Determine Level of 99 From Chart Documentation HPI Elements (record 4 of 9) ContextModifiers Assoc signs Other 21

22. Determine Level of 99 From Chart Documentation HPI Always record FOUR Less than 4 means highest EM Level is: Level 2 New Patient Level 3 Est. Patient 22

23. Determine Level of 99 From Chart Documentation HPI 4 or more means no restriction on choice of EM level HPI examples available – email me 23

24. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History 24

25. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Inventory of body systems obtained through questions to identify signs or symptoms 25

26. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Patient or staff can fill out ROS Physician must review ROS and make notation in chart 26

27. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Does not need to be re-recorded if there is evidence physician reviewed & updated prior ROS Once done, always done 27

28. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Review & update may be documented by: describing new ROS information, or describing new ROS information, or noting there is no change in information; and noting there is no change in information; and noting date and location of earlier ROS noting date and location of earlier ROS 28

29. Determine Level of 99 From Chart Documentation Review of Systems (ROS) A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. ROS must be reviewed by pt & doc validate each visit 29

30. Determine Level of 99 From Chart Documentation Review of Systems (ROS) A note indicating all systems are negative is permissible 30

31. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Elements (record 10 of 14) ConstitutionalEyes Ears nose mouth throat CardiovascularRespiratoryGastrointestinal 31

32. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Elements (record 10 of 14) GenitourinaryMusculoskeletalIntegumentaryNeurologicalPsychiatricEndocrine 32

33. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Elements (record 10 of 14) Hematologic/LymphaticAllergic/Immunologic 33

34. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Always record TEN 2 – 9 means highest EM is: Level 3 New Patient Level 3 New Patient Level 4 Est. Patient Level 4 Est. Patient 34

35. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History 35

36. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Patient or staff can fill out PFSH Physician must review PFSH and make notation in chart 36

37. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) No need to re-record if evidence that physician reviewed & updated prior PFSH Once done, always done 37

38. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Review & update may be documented by: describing new PFSH information, or describing new PFSH information, or noting there is no change in information; and noting there is no change in information; and noting date and location of earlier PFSH noting date and location of earlier PFSH 38

39. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Past History elements (record 1 of 7) Prior major illness & injury Prior operation Prior hospitalization Current meds 39

40. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Personal History elements (record 1 of 7) Allergies Immunization status Dietary status 40

41. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Social History elements (record 1 of 7) Marital status/Living arrangement Current employment Occupational history Use of drugs, alcohol, tobacco 41

42. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Social History elements (record 1 of 7) Level education Sexual history Other social factors 42

43. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Family History elements (record 1 of 3) Medical events Diseases Hereditary conditions 43

44. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Always record ONE FROM EACH CATEGORY Recording 1 means highest EM is: Level 3 New Patient Level 3 New Patient Level 4 Est Patient Level 4 Est Patient 44

45. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History (to review) Every patient: document history as if supporting highest level EM ~Good medicine ~Good medicine ~Reveals issues needing management ~Reveals issues needing management 45

46. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History ~Minimizes History as factor in grading final EM ~Minimizes History as factor in grading final EM 46

47. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History 2. Examination 3. Medical Decision Making (MDM) 47

48. Determine Level of 99 From Chart Documentation Examination What level examination is justified? Extent of examination is based on -Clinical judgment -Clinical judgment -Patient history -Patient history -Nature of presenting problems -Nature of presenting problems 48

49. Determine Level of 99 From Chart Documentation Examination Elements (of 14, record all that apply) Visual Acuity Confrontation VF Ocular motility test Conjunctiva Ocular adnexae Pupils & Irises 49

50. Determine Level of 99 From Chart Documentation Examination Elements (of 14, record all that apply) Corneas Anterior Chamber LensesIOP Optic Discs Posterior Segments 50

51. Determine Level of 99 From Chart Documentation Examination Elements (of 14, record all that apply) Orientation Mood and affect 51

52. Determine Level of 99 From Chart Documentation Examination Elements Visual Acuity Not refraction 52

53. Determine Level of 99 From Chart Documentation Examination Elements Confrontation VF Gross visual field testing 53

54. Determine Level of 99 From Chart Documentation Examination Elements Ocular motility test Primary gaze alignment 54

55. Determine Level of 99 From Chart Documentation Examination Elements Conjunctiva Bulbar & Palpebral 55

56. Determine Level of 99 From Chart Documentation Examination Elements Ocular adnexae Lids (eg, ptosis or lagophthalmos) Lacrimal glands Lacrimal drainage Orbits Preauricular lymph nodes 56

57. Determine Level of 99 From Chart Documentation Examination Elements Pupils & Irises Shape Direct & consensual reaction (afferent pupil) Size (eg, anisocoria) Morphology (shape, form) 57

58. Determine Level of 99 From Chart Documentation Examination Elements Corneas @ slit lamp EpitheliumStromaEndothelium Tear film 58

59. Determine Level of 99 From Chart Documentation Examination Elements Anterior chambers @ slit lamp DepthCellsFlare 59

60. Determine Level of 99 From Chart Documentation Examination Elements Lenses @ slit lamp Clarity Anterior & posterior capsule CortexNucleus 60

61. Determine Level of 99 From Chart Documentation Examination Elements IOP Except in children & Patients with trauma or infectious disease 61

62. Determine Level of 99 From Chart Documentation Examination Elements Optic Discs Thru dilated pupils, unless contraindicated: Size C/D ratio Appearance (eg, atrophy, cupping, tumor elevation) Nerve fiber layer 62

63. Determine Level of 99 From Chart Documentation Examination Elements Posterior Segments Thru dilated pupils, unless contraindicated: Retina & vessels eg, exudates & hemorrhages 63

64. Determine Level of 99 From Chart Documentation Examination Elements Orientation (mental status) To time, place and person Brief assessment Brief assessment 64

65. Determine Level of 99 From Chart Documentation Examination Elements Mood and affect (mental status) eg, depression, anxiety, agitation Brief assessment 65

66. Determine Level of 99 From Chart Documentation Examination, Scoring New Min. Elements Needed 992011 992026 (orientation + mood + 4) 992039 (orientation + mood + 7) 992041 st 12 + 1 mental 992051 st 12 + 1 mental 66

67. Determine Level of 99 From Chart Documentation Examination Elements (of 14, record all that apply) 1. Visual Acuity 2. Confrontation VF 3. Ocular motility test 4. Conjunctiva 5. Ocular adnexae 6. Pupils & Irises 67

68. Determine Level of 99 From Chart Documentation Examination Elements (of 14, record all that apply) 7. Corneas 8. Anterior Chamber 9. Lenses 10. IOP 11. Optic Discs 12. Posterior Segments 68

69. Determine Level of 99 From Chart Documentation Examination Elements (of 14, record all that apply) 13. Orientation (mental) 14. Mood and affect (mental) 69

70. Determine Level of 99 From Chart Documentation Examination, Scoring Est Min. Elements Needed 992110 992121 992136 (orientation + mood + 4) 992149 (orientation + mood + 7) 992151 st 12 + 1 mental 70

71. Determine Level of 99 From Chart Documentation Examination, Scoring Break points: 1, 6, 9, 12 Blank boxes on exam form, for counting 71

72. Determine Level of 99 From Chart Documentation Could stop scoring now, for est. patient – Need only 2 of 3 Main Elements Example: History & Examination 72

73. Determine Level of 99 From Chart Documentation For Established Patient, most cases Examination Level = level of EM 73

74. Determine Level of 99 From Chart Documentation For Hx & Exam, counting system used Easy to understand & score MDM – not so much 74

75. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History 2. Examination 3. Medical Decision Making (MDM) 75

76. Determine Level of 99 From Chart Documentation Medical Decision Making elements a) Diagnosis & Management Options b) Complexity c) Risk (2 of 3 needed, new & est) (2 of 3 needed, new & est) 76

77. Determine Level of 99 From Chart Documentation Medical Decision Making elements a) Diagnosis & Management Options b) Complexity c) Risk 77

78. Determine Level of 99 From Chart Documentation Diagnosis & Management Options 1997 DG Number of possible diagnoses or number of management options is based on: Number of possible diagnoses or number of management options is based on: Number & types of problems addressed, Number & types of problems addressed, Complexity of establishing diagnosis, and Complexity of establishing diagnosis, and Management decisions Management decisions 78

79. Determine Level of 99 From Chart Documentation Diagnosis & Management Options 1997 DG Diagnosed problem decisions are easier Diagnosed problem decisions are easier Un-diagnosed problem decisions are harder Un-diagnosed problem decisions are harder 79

80. Determine Level of 99 From Chart Documentation Diagnosis & Management Options 1997 DG Number & type diagnostic tests indicates number of possible diagnoses Number & type diagnostic tests indicates number of possible diagnoses Improving or resolving problems are less complex Improving or resolving problems are less complex Worsening or failing-to-change-as-expected problems are more complex Worsening or failing-to-change-as-expected problems are more complex 80

81. Determine Level of 99 From Chart Documentation Diagnosis & Management Options 1997 DG Need to seek advice from others indicates complexity Need to seek advice from others indicates complexity 81

82. Determine Level of 99 From Chart Documentation Diagnosis & Management Options Choices for grading None None Minimal Minimal Limited Limited Multiple Multiple Extensive Extensive 82

83. Determine Level of 99 From Chart Documentation Want help to grade ?? 83

84. Determine Level of 99 From Chart Documentation Diagnosis & Management Options CPT & DG: No point system but, HGS Administrators (Medicare) made a point system 84

85. Determine Level of 99 From Chart Documentation Problem TypeCount of Problems x Points =Problem Points Self-limited or minor (maximum of 2) 1 Established problem, stable or improving 1 Established problem, worsening or failing to change as expected 2 New problem, with no additional work-up planned (maximum 1) 3 New problem, with additional work-up planned 4 85

86. Determine Level of 99 From Chart Documentation Diagnosis & Management Options Total Supports 1 99201 & 99211 1 99201 & 99211 1 99202 & 99212 1 99202 & 99212 2 99203 & 99213 2 99203 & 99213 3 99204 & 99214 3 99204 & 99214 4 99205 & 99215 4 99205 & 99215 86

87. Determine Level of 99 From Chart Documentation Diagnosis & Management Options Exam form “Diagnosis” section, add: “New – chronic – improved – stable – worse” 87

88. Determine Level of 99 From Chart Documentation Medical Decision Making elements a) Diagnosis & Management Options b) Complexity c) Risk (2 of 3 needed, new & est) (2 of 3 needed, new & est) 88

89. Determine Level of 99 From Chart Documentation Complexity 1997 DG Amount and complexity is based on types of diagnostic tests ordered or reviewed 89

90. Determine Level of 99 From Chart Documentation Complexity 1997 DG Decision to obtain and review old medical records increases amount & complexity Decision to obtain history from source other than patient increases amount & complexity 90

91. Determine Level of 99 From Chart Documentation Complexity Choices for grading are Minimal Minimal Limited Limited Multiple Multiple Extensive Extensive 91

92. Determine Level of 99 From Chart Documentation Want help to grade ?? 92

93. Determine Level of 99 From Chart Documentation Complexity CPT & DG: No point system but HSA Administrators & Trailblazer made point system file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/A-O/Loose Pages/09 Complexity.xlsx file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/A-O/Loose Pages/09 Complexity.xlsx 93

94. Determine Level of 99 From Chart Documentation Complexity TotalSupports 0 or 199201 & 99211 0 or1 99202 & 99212 299203 & 99213 299203 & 99213 399204 & 99214 399204 & 99214 499205 & 99215 499205 & 99215 94

95. Determine Level of 99 From Chart Documentation Medical Decision Making elements a) Diagnosis & Management Options b) Complexity c) Risk (2 of 3 needed, new & est) 95

96. Determine Level of 99 From Chart Documentation Risk (broad scope) 1997 DG The risk of (a) significant complications (a) significant complications (b) morbidity, and/or (b) morbidity, and/or (c) mortality (c) mortality is based on risks associated with 96

97. Determine Level of 99 From Chart Documentation Risk 1997 DG (1) presenting problems (1) presenting problems (2) diagnostic procedures, and (2) diagnostic procedures, and (3) possible management options (3) possible management options 97

98. Determine Level of 99 From Chart Documentation Risk 1997 DG Determination of risk is complex and not readily quantifiable not readily quantifiable 98

99. Determine Level of 99 From Chart Documentation Risk 1997 DG Risk is related to disease process anticipated between present encounter and next one Risk is based on risk during and immediately following procedures or treatment. 99

100. Determine Level of 99 From Chart Documentation Risk 1997 DG A table may be used to help determine risk Highest level of risk in any one category determines overall risk 100

101. Determine Level of 99 From Chart Documentation Risk 1997 DG table for general medicine AAO created Risk Table for eyes – unofficial file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/A-O/Loose Pages/10 Risk Chart AAO.xls file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/A-O/Loose Pages/10 Risk Chart AAO.xls 101

102. Determine Level of 99 From Chart Documentation Risk Rx med or Cataract surgery referral = Moderate risk (level 4 new & est) Cataract surgery referral with risk factors = High risk (level 5 new & est) 102

103. Determine Level of 99 From Chart Documentation Risk TotalSupports TotalSupports Minimal199201 & 99211 Minimal199202 & 99212 Low299203 & 99213 Modrt399204 & 99214 High499205 & 99215 103

104. Determine Level of 99 From Chart Documentation Grading Overall MDM 104

105. Determine Level of 99 From Chart Documentation Grading Overall MDM Of 3 elements (Diag & Mgmt, Complxty, Risk) Use “Diagnosis & Management Options” + “Risk” (ignore Complexity) Lowest level of support between the two = level of MDM level of MDM 105

106. Determine Level of 99 From Chart Documentation For New Patient Lowest between Exam and MDM = level of EM 106

107. Determine Level of 99 From Chart Documentation Review of Big Picture a) Every patient, document history as if supporting highest level EM 107

108. Determine Level of 99 From Chart Documentation Review of Big Picture b) Established Patient Examination Level = level of EM Examination Level = level of EM 108

109. Determine Level of 99 From Chart Documentation Review of Big Picture c) New Patient Grade 2 MDM elements Grade 2 MDM elements Lowest level between Exam and MDM = Lowest level between Exam and MDM = level of EM level of EM 109

110. Determine Level of 99 From Chart Documentation Recommendation For paper charting Use EM recording form similar to sample For Paperless charting Adjust History section to accept multiple CC Keep “Diagnosis & Management Options” and “Risk” chart handy 110

111. CPT examples of EM Appendix C of CPT manual 111

112. CPT examples of EM 99201 Initial office visit for 10-yo for determination of visual acuity as part of summer camp physical (does not include refraction) Non-medical 112

113. CPT examples of EM 99203 Initial office visit for 55 yo with chronic blepharitis. History of many medications. Simple but not level 2 113

114. CPT examples of EM 99203 Initial office visit for 18 yo with 2-day history of acute conjunctivitis. Extensive history of possible exposures, prior normal ocular history, medication use is obtained. Simple but not level 2 114

115. CPT examples of EM 99205 Initial office visit for 29 yo with acute orbital congestion, lid retraction, bilateral visual loss from optic neuropathy. Vision loss 115

116. CPT examples of EM 99205 Initial office visit for 70 yo diabetic with progressive VF loss, advanced optic disc cupping, neovascularization of retina. Vision loss, loss of function 116

117. CPT examples of EM 99211 Multiple scenarios: ~ New copy of lost prescription ~ Dressing change ~ Release to return to school ~ Return to work certificate ~ Blood pressure check ~ Instruction in use of a medical device 117

118. CPT examples of EM 99212 Office evaluation of possible purulent bacterial conjunctivitis with 1-to-2 day history of redness and discharge, 16 yo, established patient. 118

119. CPT examples of EM 99213 Office visit for 65 yo, established patient, with primary glaucoma for interval determination of IOP and possible adjustment of medication. “IOP check” “IOP check” 119

120. CPT examples of EM 99214 Office visit for 68 yo, established patient, sudden onset of multiple flashes and floaters in right eye due to posterior vitreous detachment. Common occurrence, serious risk but benign outcome. Common occurrence, serious risk but benign outcome. 120

121. CPT examples of EM 99214 Office visit for adult diabetic established patient with past history of recurrent sinusitis who presents with 1-week history of double vision. Diabetic complication 121

122. Prolonged Service file://localhost/Users/alanhomestead/Do cuments/My Documents B 3-8- 13/Adventures 11-3-12/O - S/Presentations/Repository of My PowerPoints/1 Topic Modules/Prolonged Srvc/Prolgd Srvc Aug 13.pptx file://localhost/Users/alanhomestead/Do cuments/My Documents B 3-8- 13/Adventures 11-3-12/O - S/Presentations/Repository of My PowerPoints/1 Topic Modules/Prolonged Srvc/Prolgd Srvc Aug 13.pptx 122